28925APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
.28925
BUIIAINGIADDRR/ESS: -
SANITARY NO.
APPLICATION SUBMITTAL DATE
WN AM x� ONE:490S
ILONTRAC17M'S NAME: LIC NO:
N/C
❑
CONTROL q
,
ARCHITECT/ENGINEER. LIC NO:
ADDRESS:
CONTACT. PHONE: -
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECP PLUMB MECH
❑ ❑
❑'S
' LICENSED CONTRACTORDECLARATION
1 hereby affirm that I am licensed under provisions of Chapter and
with Sectionmylicense is
and e) of ecDivision 3 of the Rosiness and Professions Code, anJ my license is
in full force and effect. �
License Class Lic.#
Dale Conan
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KITCHEN REMODEL
ODITION (]PLUMBING RE -PIPE
❑ M LTI-UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT •
❑BATH REMODEVRF.PAIR (] DEMOLITION
❑ OTHER
PERMIT ISSUANCE
APPLIANCES—RESIDENTIAL
ARCHITECTS DECLARATION
Iundenwnd my plans shall bassist as public records
PANELS
UP T02W AMPS
Licensed Pmfessmnal
' OWNER -BUILDER DECLARATION ON
1 hereby affirm that am exempt fromm thee do Commmors License Law for the
fallowing reason. (Second ]0315, Business and Professions Code: Any city or countySIGNS
which requires a permit to construct, alterro
, Impve, demolish, or repair any stno:tnre
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions ofthe Contractors License Law (Chapter 9
(commencing with Section ]II(I) of Division 3 ofthe Business and Professions Code)or
g that he is exempt therefrom and the basis for the alleged exemption. Any violation of
o Section 7031.5 by any appliamdfor a permit subjects the applicant tm a civil penalty of
Kt rethnn tivm hundred dollars (5500).
as owner or he rt,onn employees with wa en us their sole nsm
ProPe Y YB penin,
will awork, and the Iwamre is actimendedomlfered for sale (Ser. 7044, Rosiness
and Propounds Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not Intended or offered for
,site IL howevemthe building or improvement is sold within one yearnfeempletion,the
ownerbudder will have the burden of provin6 that he did not M1uiid ar improve forur
p-
poseo.
❑ acomplainsi-
I, as owner of the property, m exclusively Protracting with licensedContractor's
consumer the p jeer (Sec, 9044,,puniness and Precisions CCode,)Tho Cnmmcmr's LI-
seLaw does not apply toanowner ofproperty who builds orimprovesthereonand
who contracts for such projects with a comractmoo licensed pursuant to the Conductor's
License 1)v.
❑I oder c ,R& rNisre un
1 11
Ow Dam
201-IOMAMPS
OVER IW AMPS
ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INET.
CQMMERCIAL,
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS—SWITCHES—FIXTURES
NEW RESIDENTIAL ELECTR SQ IT.
SQ. FT. FLOOR AREA
$/SQ. FT.
,
TOTAL:
QTy. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER — URAIN@VEN—WATER(EA)
VALUATION
\ORP OMPE SA NDF,CLARATION
Iffir fpwgtyofperjury oneof the following declarations:Ihl main maCertifcate of Consentmself-insure for Wrrkere Compen-
saber, as provided for by Section 37W of the LOm, Cade, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required b on
37M oflhe Lane, Code, for the performance of the work rorwhich this itis imam.
My Workers Compensation tnsumnce Perrier and Policy number aa:
Carrier: PION No.:
CERTIFICATEOMPE SATIONII EXEMPTION MOM WORK S'
COMPENSATION INSURANCE
(This section need not be completed it he porat is for one h Bred dollars t$1 W)
or Ions.)
Icerify that in 'be perrnrmanceofthe work far whichot it is noued,"hall
norempiny any person in any manner sit as m become subject m t Workers' Cnmpen-
smirn Lawsof Califomia.Daa
Applicant
BACKFLOW TELT. DEVIC
DR —FLOOR, ROOF, AREA,C D.
STORIES
OCC. GROUP
•
TYPE CONSTRUCTION
APN
'
FIXTURES— PER TRAP
GAS — EA. SYSTEM -1 INC. 4 OUTLETS
GAS — EA. SYSTEM -OVER 4(EA)
GREASFJINDUSTRL WASTE INTERCEPT R _
BUIL GDIVISiES
GREA. TRAP
PLANCHECK FEE
ENERGY FEE
E R ANITARY—STORM EA. PT.
-
TERHEATERWNENT E T
GRADING P
NOTICE TO APPLICANT: If, after making this CeriOcdte OfEx
become subject to the Workers Compensation provisions of the L
forthwith comply with such provisions or this permit shall be dee
CONSTRUCTION LENDING AGENCY
I hereby affimt Not there is a construction lending agency[
the work for which this permit is issued (Sec. 3097, Civ, C.)
Lenders Name
m n, sh
e m st
ed 'd. u
rt he promornneeof
WATER SY ATIpiG
SOILS FE
A V
PAID
a ReceiptM
W ESIDENTIALP B. SQ. Up
TOTAL:
Lenders Address
1 certify that 1 have read this application and store that the we information is
correct. l agree to comply with all city and county mdinanee.ands telawsrelmingto
building construction, and hereby authorize repro.ontativesnRhis ci to enter upon the
ubove-emmioned prn,voy for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of and a m
liabilities,judgmems, costs and expenses% Inch may in anyway accrue ag � id City
me onsequence of the granting rf this permit,
APPLICANT 'UNDERSTA DS AND WILL COMPLY WITH ALL NONPOINTAIR
SOURCE RE iULATfO
`
C ate
H DOI1S MATERIALS DISCLOSURE
P
illtheapp i` lansre building occupant stere or handle hazardous material
as deft d by the Cupertino Municipal Code,Chapter 9,12, add [Le Health and Safety'
Code, Section 25534(a)'p
❑Yes 7 N -
Will the applicnot or furore building wcapdm use egdipment or devices which
emit hazardous air contaminants as defined by the Bay Area At,Quality Management
Dtimall
❑Yen Bryn
I have read the hazardous materials requirements under Chapter 695 of the Cali-
Pomla Health &Safety Code, e a Sectors 25505. 25533 ad 25534. I understand th that if the
building uiremet, icallywhich ostlic met
of the requirements which mustMmet prionoisxuance ofe Cenificam of Occupancy.
etpaux t ismyrespo.Cv"tym notifylheoc ry.
-
TOTAL:
BUILDING FEE
QTY MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
,ELECTRIC P6 _
ALTER OR ADD TO MECH.
PLUMBING FEE
HANDLING UNIT TO 10,001 CFM)
MECHANICALFEE
AIR HANDLING UNIT (OVER IO,WO CFM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DUCf)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,001) BTU)
HEATING UNIT (OVER I00,0(10 BTU) is
PAID
Dal. Receiptli
VENTILATION FAN (SINGLE RESID) !' t
BOILER—COMP (JHP QR IOO,OW BTU)
-
I TO L:
,
BOILER— COMP (OVER I00,000 BTU) ®
AIR CONDITIONER �Y r^Ns�
._-' V
ISSUANCE DAT
ISSUED BN
NEW RESIDENTIAL MECH �- 1v I SQ.
Dwaine, authonzedagenl Date
- TOTAL:
OFFICE